If we were to roll back the years and look at the growth and change in Rural and Remote Health, we could surmise that the interest and productivity related to rural health has grown steadily and in some cases surpassed expectations. In 2008, we successfully negotiated for the creation of the North American section within this journal. I became co-editor and in this role had the privilege and pleasure to work with the journal staff, fellow editors and board members. I appreciate their diligence, conscientiousness, and perseverance in making the rural agenda their priority. Their bottom line is to communicate about rural while also stimulating change to benefit rural residents and healthcare workers in the range of rural and remote settings that exist. At the end of September, I stepped down as regional editor for North America and am so pleased that Rebecca Schiff and Bronwyn Fields have willingly stepped into the co-editor roles. They both have substantial skills and knowledge to offer, and under their guidance the North American section will continue to grow and prosper.
In looking back over the last eight years, I have been impressed by the number of topics related to rural that are being addressed through sound research. A wide variety of research methodologies and large teams are working collaboratively to conduct the investigations. It has also been nice to see the number of students or recent graduates involved in the publications. If I had one wish, it would be that researchers clearly identify their specific research topic within a larger research framework that is specific to rural. Having such a framework has several advantages, including being able to easily identify the strengths and gaps of rural health research. It is not deficit-driven but focuses on the unique features of each rural community rather than working from a premise that rural communities are 'less than' urban cities. Another benefit is for the end-users - be they students, other researchers, decision makers and of course community members - who can more easily access and use the findings in their everyday lives. In addition, applying a framework can guide students to choose research questions for their own work; scoping reviews on rural health that are based upon the framework suggested here can assist in this process. A final benefit is that having a framework communicates to others, especially non-rural researchers, that there is substance to what we do and we have a direction and a plan to get there.
I think the time is right to identify and apply a general rural health research framework that can guide researchers in planning research projects and decision makers in developing policies and implementing programs to address rural issues. Figure 1 is a visual representation of the framework originally introduced in the book Health in rural Canada to group and align the content by topic1. There are three interrelated areas: 'places matter to health', 'diversity in rural places', and 'rural places are dynamic'. These three areas are encircled by the social determinants of health, which connects the three areas.
'Places matter to health' refers to the impact of place on health; in this instance place refers to both physical space (geography) and social space (settings that have meaning and identity). A number of geographic variations in rural and remote settings both positively and negatively impact on individual and community health. Differences in health status, mortality and morbidity can vary by the economy, which is often determined by the geography of the rural setting. Hence, employment may be based on agricultural, mining or logging industries, which are determined by the type of landscape and presence of specific kinds of resources. We also know that health status can vary by social space, which includes the ways in which communities are organized and the types of people that make up the community. Focusing on place and how it matters to health can lead to questions such as: 'If rural community A and rural community B have the same geographic features, what is the basis for their differences in health status? Are there variations in the way in which the communities work together? What else is at play here? Is the combination of all of these factors what is most important?' Determining the answers will help guide the development of appropriate health programs and policies to address any negative health outcomes.
'Diversity in rural places' focuses on the wide variation of rural and remote settings and the people who reside within them. In this instance, variation can refer to the different ethnic and racial groups, historical circumstances and sociopolitical dynamics of rural and remote settings. Examining these factors, numerous research questions can be asked, including concentrating on rural communities experiencing an influx of refugees from countries that are very different to those from which migration has happened in the past. This may lead us to ask about the impact on health status indicators and on the social relationships in these communities. One other example of diversity of rural places that has not been fully addressed is the experiences of lesbian, gay, bisexual, transgender and intersex individuals and their challenges in receiving health care. Such a sensitive topic can be difficult to examine but has the potential to positively impact the individuals who are at the heart of the investigation.
'Rural places are dynamic' is the final interrelated area of the framework. Those who are familiar with rural and remote communities are fully aware that these communities are constantly changing. Researchers need to be on the lookout for cutting edge issues that can be systematically addressed while also being prepared to deal with issues that may cause discomfort for the researcher, participant and end users such as decision makers. One example is the area of environmental change and the impact of such changes on human health. More specifically, concerns over climate change and the reduction of available land for producing food supplies is an area that can be investigated. The results of such a study may lead to challenges; expectations about applying the findings may not be realized if decision makers are not fully prepared to deal with outcomes from the different stakeholders.
Conducting rural research within a framework such as the one suggested here will identify topics that need to be addressed and in turn expand our knowledge base and potentially enhance our political influence. But carrying out research within a specific framework is not enough; research must be conducted by ethical standards and based within principles that foster collaboration, engagement and meaningful exchange between researchers and community members, policy makers, and other relevant individuals and agencies.
There are many examples in Rural and Remote Health of well crafted and implemented research that has benefited our knowledge base and helped rural residents. Applying the framework suggested here has the potential to reiterate the dynamic nature of rural from a strengths rather than deficit basis. Identifying individual research studies and research programs within this framework will strengthen the theoretical component of rural health and rural research while also enhancing communication about the goals and objectives of the investigations. Applying this framework can also foster collaborations with other researchers and partnerships with community residents and decision makers. 'The time is now' to apply a rural health research framework and move forward in our understanding of rural health.
Figure 1: A general rural health research framework1.
1. Kulig JC, Williams AM (Eds). Health in rural Canada. Seattle: University of Washington Press, 2012.